Synopsis of main recommendations

AETIOLOGY AND EPIDEMIOLOGY

Streptococcus pneumoniae is the most common bacterial cause of pneumonia in childhood [ II]. Age is a good predictor of the likely pathogens:

Viruses are most commonly found as a cause in younger children. In older children, when a bacterial cause is found, it is most commonly S pneumoniae followed by mycoplasma and chlamydial pneumonia [II].
A significant proportion of cases of CAP (840%) represent a mixed infection [II]. Viruses alone appear to account for 1435% of CAP in childhood [II]. In 2060% of cases a pathogen is not identified [II]. The mortality from CAP in children in developed countries is low [Ib].

CLINICAL FEATURES
Bacterial pneumonia should be considered in children aged up to 3 years when there is fever of >38.5C together with chest recession and a respiratory rate of >50/min [B]. For older children a history of difficulty in breathing is more helpful than clinical signs. If wheeze is present in a preschool child, primary bacterial pneumonia is unlikely [B].

RADIOLOGICAL INVESTIGATIONS
Chest radiography should not be performed routinely in children with mild uncomplicated acute lower respiratory tract infec tion [A]. Radiographic findings are poor indicators of aetiology. Follow up chest radiography should only be performed after lobar collapse, an apparent round pneumonia, or for continuing symptoms [C].

GENERAL INVESTIGATIONS
Pulse oximetry should be performed in every child admitted to hospital with pneumonia [A]. Acute phase reactants do not distinguish between bacterial and viral infections in children and should not be measured rout inely [A].

MICROBIOLOGICAL INVESTIGATIONS
There is no indication for microbiological investigation of the child with pneumonia in the community. Blood cultures should be performed in all children suspected of having bacterial pneumonia [ B]. Acute serum samples should be saved and a convalescent sample taken in cases where a microbiological diagnosis was not reached during the acute illness [B]. Nasopharyngeal aspirates from all children under the age of 18 months should be sent for viral antigen detection (such as immunofluoresence) with or without viral culture [B]. When significant pleural fluid is present, it should be aspirated for diagnostic purposes, sent for microscopic examination and culture, and a specimen saved for bacterial antigen detection [B].

SEVERITY ASSESSMENT
Indicators for admission to hospital in infants:

oxygen saturation <92%, cyanosis; respiratory rate >70 beats/min; difficulty in breathing; intermittent apnoea, grunting; not feeding; family not able to provide appropriate observation or supervision.

Synopsis of main recommendations (continued)

INDICATORS FOR ADMISSION TO HOSPITAL IN OLDER CHILDREN:
oxygen saturation <92%, cyanosis; respiratory rate >50 breaths/min; difficulty in breathing; grunting; signs of dehydration; family not able to provide appropriate observation or supervision.

GENERAL MANAGEMENT
The child cared for at home should be reviewed by a general practitioner if deteriorating, or if not improving after 48 hou rs on treatment [D]. Families of children who are well enough to be cared for at home need information on managing pyrexia, preventing dehydration, and identifying any deterioration [D].

 Patients whose oxygen saturation is 92% or less while breathing air should be treated with oxygen given by nasal cannulae, head box, or face mask to maintain oxygen saturation above 92% [A]. Agitation may be an indication that the child is hypoxic. Nasogastric tubes may compromise breathing and should therefore be avoided in severely ill children and especially i n infants with small nasal passages. If used, the smallest tube should be passed down the smallest nostril [D]. Intravenous fluids, if needed, should be given at 80% basal levels and serum electrolytes monitored [C]. Chest physiotherapy is not beneficial and should not be performed in children with pneumonia [B]. Antipyretics and analgesics can be used to keep the child comfortable and to help coughing. In the ill child, minimal handling may reduce metabolic and oxygen requirements. Patients on oxygen therapy should have at least 4 hourly observations including oxygen saturation [D].

ANTIBIOTIC MANAGEMENT
Young children presenting with mild symptoms of lower respiratory tract infection need not be treated with antibiotics [ B]. Amoxicillin is first choice for oral antibiotic therapy in children under the age of 5 years because it is effective against the majority of pathogens which cause CAP in this group, is well tolerated, and cheap. Alternatives are co-amoxiclav, cefaclor, erythromycin, clarithromycin and azithromycin [B]. Because mycoplasma pneumonia is more prevalent in older children, macrolide antibiotics may be used as first line empirical treatment in children aged 5 and above [D]. Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected [D]. Amoxicillin should be used as first line treatment at any age if S pneumoniae is thought to be the likely pathogen [ B]. If Staphylococcus aureus is thought the likely pathogen, a macrolide or combination of flucloxacillin with amoxicillin is appropriate [D]. Although there appears to be no difference in response to conventional antibiotic treatment in children with penicillin res istant S pneumoniae, the data are limited and the majority of children in these studies were not treated with oral -lactam agents jalone. Antibiotics administered orally are safe and effective for children presenting with CAP [ A]. Intravenous antibiotics should be used in the treatment of pneumonia in children when the child is unable to absorb oral antibiotics (for example, because of vomiting) or presents with severe signs and symptoms [D]. Appropriate intravenous antibiotics for severe pneumonia include co-amoxiclav, cefuroxime, and cefotaxime. If clinical or microbiological data suggest that S pneumoniae is the causative organism, amoxicillin, ampicillin, or penicillin alone may be used [D]. In a patient who is receiving intravenous antibiotic therapy for the treatment of CAP, oral treatment should be co nsidered if there is clear evidence of improvement [D].

COMPLICATIONS
If a child remains pyrexial or unwell 48 hours after admission with pneumonia, re-evaluation is necessary with consideration given to possible complications [D].